ABSTRACT Background Electrolyte disturbances are common but are frequently overlooked. We investigated whether clinical practice and outcomes changed after implementation of electronic alerts (e-alerts) for electrolyte disturbances. Methods This single-center, retrospective cohort study was conducted at a university hospital that implemented the e-alert system “Electrolyte Busters” in May 2021. E-alert criteria were serum sodium <125 or >160 mEq/L, potassium <2.5 or >6.0 mEq/L, corrected calcium <7.5 or >11.5 mg/dL, and magnesium <1.0 or >4.0 mg/dL. Outcomes among patients with hyponatremia were compared between the years before and after e-alert implementation. Urinary chemistry measurements, treatment and overcorrection were analyzed using logistic regression. Referral and fall rates were analyzed using incidence rate ratios (IRRs) and negative binomial regression, respectively. Length of stay (LOS) was compared using the Mann–Whitney U test. Results Data from 36 379 pre-intervention and 37 395 post-intervention patients were analyzed. Median age was 62 years, and 48% were male. After e-alert implementation, nephrology referrals for hyponatremia increased from 1.1 to 2.3 per month [IRR (95% confidence interval) 2.07 (1.04–4.36)]. Urinary chemistry measurements increased [odds ratio (OR) (95% confidence interval) 1.62 (1.08–2.44)], whereas untreated cases decreased [OR 0.31 (0.19–0.53)]. Median (interquartile range) LOS decreased from 27 (15–47) to 20 (12–36) days (P = .01). Hyponatremia overcorrection [OR 0.64 (0.36–1.14)] and fall rates [IRR 0.82 (0.36–1.69)] showed downward trends. Conclusion E-alerts were significantly associated with improved diagnostic evaluation and therapeutic interventions, and shorter LOS among patients with hyponatremia.
Albuminuria reflects cardiorenal vulnerability and has been associated with adverse outcomes in heart failure (HF). However, its relationship with the total burden of recurrent worsening HF (WHF) events in ambulatory patients remains insufficiently defined. We conducted a prospective, multicenter cohort study including 940 ambulatory patients with chronic HF from the Spanish Cardiorenal Registry (derivation cohort) and externally validated the findings in 335 patients attending the Heart Failure Clinic of Hospital Clínico Universitario de Valencia, Valencia, Spain. UACR was measured at baseline and analyzed as <30 vs ≥30 mg/g and as a log-transformed continuous variable. The primary endpoint was total WHF events. Recurrent events were analyzed using negative binomial regression. In the derivation cohort (mean age 72 ± 13 years, 36.7% women), the median eGFR and UACR were 54 ml/min/1.73m² (IQR: 37–77) and 20 mg/g (IQR: 10–70), respectively, and 379 patients (40.3%) had UACR values ≥30 mg/g. During a median follow-up of 1.05 years, 477 WHF events occurred in 197 patients. After multivariable adjustment, UACR ≥30 mg/g independently predicted total WHF events (IRR 1.55; 95% CI 1.12–2.15; p = 0.009). Continuous analyses confirmed a graded, non-linear association across the UACR spectrum (p = 0.017). Risk increased continuously across the UACR spectrum with no threshold at 30 mg/g: compared with a UACR of 10 mg/g, a value of 25 mg/g, still within the conventional normal range, was associated with a higher rate of recurrent WHF events (IRR 1.10; 95% CI 1.03–1.18; p = 0.006). Consistent results were obtained in the validation cohort. Elevated UACR independently predicts the cumulative burden of recurrent WHF in ambulatory chronic HF, with risk already detectable below the conventional 30 mg/g threshold. Whether measuring UACR improves clinical decision-making requires prospective evaluation.
ABSTRACT Mechanical massage may be an overlooked exposure in patients presenting with renal hemorrhage. A 53-year-old man with end-stage renal disease receiving hemodialysis experienced perirenal hemorrhage followed nine months later by a second episode in the contralateral kidney. During the first episode, a few hours after a vigorous massage chair session, the patient presented with abdominal pain and a decrease in hemoglobin. Computed tomography (CT) demonstrated a large right perirenal and pararenal hematoma. Right renal artery coil embolization was performed despite no active bleeding on angiography. Nine months later, shortly after another massage session in the same chair, the patient presented again with abdominal pain and a decrease in hemoglobin. This time, CT demonstrated a large left perirenal hematoma with active bleeding, prompting left renal artery embolization. This repeated temporal association adds corroborative evidence to an earlier single report of perirenal hemorrhage after chair massage in a patient with polycystic kidney disease. Cystic abnormalities and possible uremic platelet dysfunction may have increased susceptibility, although causation cannot be established. Targeted questioning about minimal trauma may identify a potentially avoidable exposure.
Erythropoiesis-stimulating agents (ESAs) are used to treat anemia in chronic kidney disease (CKD). ESAs have been associated with increased thrombotic risk, but the underlying mechanisms remain unclear. Given its antiplatelet effects and widespread use in cardiovascular prevention, we hypothesized that concomitant acetylsalicylic acid (ASA) attenuates ESA-induced prothrombotic alterations in hemostasis in patients with CKD. We conducted a prospective single-arm, repeated-measures, interventional phase 4 study in 27 individuals with advanced CKD (hemodialysis, peritoneal dialysis, and non-dialysis). The study comprised four consecutive 4-week phases: ESA washout, ESA treatment, ESA plus ASA (75 mg daily), and post-treatment washout. At the end of each phase, we assessed platelet function, whole-blood coagulation, endothelial activation, coagulation activation, and fibrinolysis. ESA treatment induced a modest and reversible increase in platelet count, whereas markers of immature platelets (IPF and H-IPF) decreased. Soluble P-selectin increased slightly during ESA treatment, indicating mild platelet and/or endothelial activation. Platelet aggregation, thromboelastometry parameters, prothrombin fragment 1 + 2, fibrin D-dimer, soluble thrombomodulin, and fibrinolysis markers remained largely unchanged throughout ESA treatment and ASA had no effect on ESA-related changes. In individuals with advanced CKD, short-term ESA treatment was associated with modest changes in platelet count and soluble P-selectin but did not result in measurable changes in platelet function, coagulation activity or fibrinolysis. ASA did not modify ESA-related effects and did not induce measurable haemostatic changes. These findings do not support a major systemic procoagulant effect of ESA, indicating that alternative mechanisms might contribute to the increased thrombotic risk observed in clinical trials.
ABSTRACT Background Kidney function is best estimated using both creatinine- and cystatin C-based estimated glomerular filtration rate (eGFR). A low ratio between eGFR based on cystatin C and eGFR based on creatinine (eGFRcys/eGFRcrea ratio <0.7), termed selective glomerular hypofiltration syndromes, is associated with increased cardiovascular risk. While differences in filtration for molecules with different molecular masses may explain this, non-renal factors such as body composition have also been proposed. We aimed to assess whether body composition determines the eGFRcys/eGFRcrea ratio in older women. Methods In 1044 women aged 75 from the Osteoporosis Prospective Risk Assessment (OPRA) cohort, followed to ages 80 (n = 715) and 85 (n = 382), we analyzed associations between the eGFRcys/eGFRcrea ratio and body composition (fat and appendicular lean mass), muscle strength (knee extension, Nm), and sarcopenia [European Working Group on Sarcopenia in Older People 2 (EWGSOP2) criteria]. Adjusted R² was reported from linear regression model assessing the eGFRcys/eGFRcrea ratio as the dependent variable adjusted for high-sensitivity C-reactive protein (hsCRP), smoking, and steroid treatment. Results Associations between body composition measures and the eGFRcys/eGFRcrea ratio were generally low and attenuated with age. No significant association was observed between fat mass and the ratio at any age. Muscle mass was positively associated with the ratio at ages 75 and 80, but not at age 85. Muscle strength was consistently associated with the eGFRcys/eGFRcrea ratio across all ages, although the proportion of explained variance declined with increasing age (adjusted R2 7.4%, 6.0%, and 2.4% at ages 75, 80, and 85, respectively). Sarcopenia was inversely associated with the ratio at ages 75 and 85, but not at age 80. Conclusion Body composition, muscle strength, and sarcopenia showed only weak associations with the eGFRcys/eGFRcrea ratio in older women. These findings suggest that non-body composition factors, including intrinsic renal mechanisms such as selective filtration of larger molecules, may contribute to a low eGFRcys/eGFRcrea ratio.
